Comorbidity In Primary Care Research Articles

Comorbidity in primary care – causal or casual? A longitudinal observational study in family medicine

BackgroundComorbidity is increasingly important in the medical literature, with ever-increasing implications for diagnosis, treatment, prognosis, management and health care. The objective of this study is to measure casual versus causal comorbidity in primary care in three family practice populations.MethodsThis is a longitudinal observational study using the Transition Project datasets. Transition Project family doctors in the Netherlands, Malta and Serbia recorded details of all patient contacts in an episode of care structure using electronic medical records and the International Classification of Primary Care, collecting data on all elements of the doctor-patient encounter, including diagnoses (1,178,178 in the Netherlands, 93,606 in Malta, 405,150 in Serbia), observing 158,370 patient years in the Netherlands, 43,577 in Malta, 72,673 in Serbia. Comorbidity was measured using the odds ratio of both conditions being incident or rest-prevalent in the same patient in one-year dataframes, as against not, corrected for the prior probability of such co-occurrence, between the 41 joint most prevalent (joint top 20) episode titles in the three populations. Specific associations were explored in different age groups to observe the changes in odds ratios with increasing age as a surrogate for a temporal or biological gradient.ResultsThe high frequency of observed comorbidity with low consistency in both clinically and statistically significant odds ratios across populations indicates more casual than causal associations. A causal relationship would be expected to be manifest more consistently across populations. Even in the minority of cases where odds ratios were consistent between countries and numerically larger, those associations were observed to weaken with increasing patient age.ConclusionAfter applying accepted criteria for testing the causality of associations, most observed primary care comorbidity is due to chance, likely as a result of increasing illness diversity.Trial registrationThis study was performed on electronic patient record datasets made publicly available by the University of Amsterdam Department of General Practice, and did not involve any patient intervention.

Phenotypes of Polish primary care patients using hierarchical clustering: Exploring the risk of mortality in the LIPIDOGEN2015 study cohort.

Comorbidities in primary care do not occur in isolation but tend to cluster together causing various clinically complex phenotypes. This study aimed to distinguish phenotype clusters and identify the risks of all-cause mortality in primary care. The baseline cohort of the LIPIDOGEN2015 sub-study involved 1779 patients recruited by 438 primary care physicians. To identify different phenotype clusters, we used hierarchical clustering and investigated differences between clinical characteristics and mortality between clusters. We then performed causal analyses using causal mediation analysis to explore potential mediators between different clusters and all-cause mortality. A total of 1756 patients were included (mean age 51.2, SD 13.0; 60.3% female), with a median follow-up of 5.7 years. Three clusters were identified: Cluster 1 (n = 543) was characterised by overweight/obesity (body mass index ≥ 25 kg/m2), older (age ≥ 65 years), more comorbidities; Cluster 2 (n = 459) was characterised by non-overweight/obesity, younger, fewer comorbidities; Cluster 3 (n = 754) was characterised by overweight/obesity, younger, fewer comorbidities. Adjusted Cox regression showed that compared with Cluster 2, Cluster 1 had a significantly higher risk of all-cause mortality (HR 3.87, 95% CI: 1.24-15.91), whereas this was insignificantly different for Cluster 3. Causal mediation analyses showed that decreased protein thiol groups mediated the hazard effect of all-cause mortality in Cluster 1 compared with Cluster 2, but not between Clusters 1 and 3. Overweight/obesity older patients with more comorbidities had the highest risk of long-term all-cause mortality, and in the young group population overweight/obesity insignificantly increased the risk in the long-term follow-up, providing a basis for stratified phenotypic risk management.

#487 Treating chronic kidney disease in Danish primary care: results from the observational ATLAS study

Abstract Background and Aims Little is known about the clinical characteristics and medical treatment of individuals with chronic Kidney Disease (CKD) in primary care clinics, including uptake of cardio-renoprotective treatments like renin-angiotensin-system inhibitors (RASi) and sodium glucose co-transporter 2 inhibitors (SGLT2i). Therefore, the aim of this study were to describe the clinical characteristics, comorbidity, and medical treatment in the primary care population with decreased estimated glomerular filtration rate (eGFR) and albuminuria. Additionally, to examine the awareness and habits of primary care physicians (PCP) in regard to CKD and treatment patterns in this high-risk patient population. Method An observational study of current CKD prevalence, treatment patterns and comorbidities in primary care based on patient record data, Data was drawn from 128/211 randomly invited primary care clinics throughout Denmark. A computerized selection identified 12 random individuals with CKD per clinic with ≥2 measurements of eGFR <60 mL/min/1.73 m2 or UACR >30 mg/g within two years. Pre-specified data collected from individual electronic health records included demographics, clinical variables, comorbidities, and relevant prescribed medications. Our analyses was strengthened by 125/128 PCP completing a questionnaire with responses regarding diagnosis, management and treatment of impaired kidney function in a real-world, primary care setting. Results Of the identified CKD study population (N = 1497), 80% had hypertension, 32% diabetes (DM), 13% heart failure (HF), 59% no DM/HF. RASi were prescribed to 65%, statins to 56%, SGTL2is to 14%, and MRAs to 8% of all individuals. Treatment patterns differed between individuals with varying comorbidities, e.g., RASi usage was higher in DM (76%) or HF (74%) vs. no DM/HF (58%), as was statin usage (76% in DM vs. 45% in no DM/HF). SGTL2i usage in CKD without DM/HF was low. Questionnaire results showed that most PCPs identified CKD using threshold eGFR <60 mL/min/1.73 m2 (62%) or UACR >30 mg/g (58%) and 62% reported initiating treatment to retard kidney function decline. 53% of PCPs reported using SGLT2is as second-line treatment for CKD. 38% of PCPs often spoke to patients with an eGFR <60 mL/min/1.73 m2 as having CKD, whilst 38% reported rarely doing so and 19% never did so. The voluntary nature of PCP study participation (accepting an invitation to participate) may have generated bias towards those with an interest in CKD. Conclusion Despite good PCP awareness and wish to use relevant guidelines, a gap exists in implementation of cardio-renoprotective treatment, especially in individuals without DM or HF. Data from both patient files and questionnaires emphasizes a need for clear recommendations to PCPs to optimize early cardio-renal protection in individuals with CKD. Applying the same systematic screening as in individuals with DM to non-diabetic populations could offer a paradigm shift for the identification, diagnosis and monitoring of CKD. Boehringer Ingelheim supported this study, but had no role in the design, analysis or interpretation of the results.

Preliminary results of “Choose Life!” - a county-wide programme for suicide prevention and mental health awareness

IntroductionSuicidality and depression awareness still remains a concern in Hungary. This programme, based on the principles of the European Union Against Depression, implemented its five steps, such as: 1. improving family doctors’ readiness to diagnose and treat depression, 2. increasing public awareness, 3. training stakeholders and community facilitators, 4. offering special help for risk groups, 5. facilitating self-help by the online tool “ifightdepression” in five of seven districts of Heves county from November 2014 until May 2016.ObjectivesWe aimed to look at some clinical outcome measures of the programme, like diagnosis density of depression in primary care before and after the intervention; diagnosis density of depression in outpatient services; suicide attempts in specialised care; and completed suicide rates.MethodsWe extracted patient turnover data from the joint database of the National Healthcare Fund and the National Directorate-General for Hospitals. Raw patient turnover data were divided by the total patient turnover in order to obtain diagnosis density. For the diagnosis of depression, we used the sum of the ICD-10 diagnoses of F32 (depressive episode) to F33 (recurrent depression) plus F4120 (mixed anxiety-depressive disorder), as family doctors tend to use these diagnoses interchangeably. For suicide attempts, we used the diagnoses X60 to X84, plus Y8700. For completed suicides we used the same diagnoses with the “deceased” flag. Diagnosis densities were compared with concurrent national data and were standardised to the long-term average. In the case of outpatient services, we only could retrieve monthly data, which we smoothed out with threemonthly moving averages.ResultsBaseline diagnosis density of depression in primary care was already 44% above the national average when the program started and after the kickoff, it shortly went up to 53,3% and remained over the baseline for as long as until 2019. Also, the recognition rates of depression with no comorbidities in primary care increased by 6%, and steadily remained over the national average until 2019. For outpatient psychiatry, there was an 8% increase in depression turnover throughout the duration of the programme. As regards to suicide attempts treated in hospital, the rates went 20% below the national averages for the duration of the programme, and mostly remained there until 2020. Fatal suicidal events accounted for five to seven deaths a year per county, therefore, simple statistical methods could not uncover significant differences.ConclusionsThese early results indicate that the programme may have been effective in terms of reinforcing the diagnostic and treatment capacities of primary care for recognising a treating depression adequately, thereby eliminating suicide risk. Further statistical exploration of the data is still needed to confirm the magnitude and the validity of these results.Disclosure of InterestNone Declared

Congenital heart disease and comorbidities in primary care: a cross-sectional study

Background/Aims Patients with congenital heart disease are living longer as a result of surgical and medical advances. General practice is key in identifying and supporting lifelong care, yet there is a lack of research into congenital heart disease in this area. This study aimed to explore the prevalence and comorbidities of patients with congenital heart disease compared to those without congenital heart disease in primary care settings in Cheshire, England. Methods This cross-sectional study used routinely collected health data from the NHS general practice population information disease database within primary care in Cheshire. Clinical read codes for congenital heart disease were added to the current data analytics risk stratification tool. Searches for patients of all ages with and without congenital heart disease were undertaken in July 2022. A total of 765 576 patients were included in the study. Results Of 765 576 patient records, 6419 patients were coded with congenital heart disease, a prevalence of 0.8%, with a comparatively younger age compared with the non-congenital heart disease cohort. Patients with congenital heart disease were three times more likely to have heart failure (odds ratio=3.36; 95% confidence interval=2.96−3.81) or stroke (odds ratio=3.58; 95% confidence interval=3.24–3.94). The most frequent comorbidities in both groups were hypertension, anxiety and depression, with no significant difference between the groups. Among those with congenital heart disease, the prevalence of a learning disability was more than eight times higher than those without congenital heart disease (odds ratio=9.23; 95% confidence interval=8.16–10.55) and autism was three times more likely (odds ratio=2.98; 95% confidence interval=2.32–3.84) in those with congenital heart disease. Conclusions There are high rates of comorbidities in the congenital heart disease population in primary care. Innovative use of digital instruments can enable identification and risk stratification of patients with congenital heart disease to support lifelong care. Congenital heart disease guidance should include primary care settings to create opportunities for mutual learning that can enhance collaborative practice.

Cost-effectiveness and cost-utility study of a psychoeducational group intervention for people with depression and physical comorbidity in primary care

ObjectiveTo evaluate the cost-effectiveness and cost-utility of a psychoeducational group intervention led by primary care (PC) nurses in relation to customary care to prevent the depression and improve quality of life in patients with physical comorbidity. DesignEconomic evaluation based on data from randomized, multicenter clinical trial with blind response variables and a one-year follow-up, carried in the context of the PSICODEP study. Location7 PC teams from Catalonia. Participants>50 year-old patients with depression and some physical comorbidity: diabetes mellitus type 2, ischemic heart disease, chronic obstructive pulmonary disease, and/or asthma. Intervention12 psychoeducational group sessions, 1 per week, led by 2 PC nurses with prior training. MeasurementsEffectiveness: depression-free days (DFD) calculated from the BDI-II and quality-adjusted life years (QALYs) from the Euroqol-5D. Direct costs: PC visits, mental health, emergencies and hospitalizations, drugs. Indirect costs: days of temporary disability (TD). The incremental cost-effectiveness ratios (ICER), cost-effectiveness (ΔCost/ΔDLD) and cost-utility (ΔCost/ΔQALY) were estimated. ResultsThe study includes 380 patients (intervention group [IG] = 204; control group [CG] = 176). 81.6% women; mean age 68.4 (SD = 8.8). The IG had a higher mean cost of visits, less of hospitalizations and less TD than the CG. The difference in costs between the IG and the CG was −357.95€ (95% CI: −2026.96 to 1311.06) at one year of follow-up. There was a mean of 11.95 (95% CI: −15.98 to 39.88) more DFD in the IG than in the CG. QALYs were similar (difference −0.01, 95% CI −0.04 to 0.05). The ICERs were 29.95€/DLD and 35,795€/QALY. ConclusionsPsychoeducational intervention is associated with an improvement in DFD, as well as a reduction in costs at 12 months, although not significantly. QALYs were very similar between groups.

Dementia and comorbidities in primary care: a scoping review

BackgroundPeople with dementia (PwD) are known to have more chronic conditions compared to those without dementia, which can impact the clinical presentation of dementia, complicate clinical management and reduce overall quality of life. While primary care providers (PCPs) are integral to dementia care, it is currently unclear how PCPs adapt dementia care practices to account for comorbidities. This scoping review maps recent literature that describes the role for PCPs in the prevention, detection/diagnosis and management of dementia in the context of comorbidities, identifies critical knowledge gaps and proposes potential avenues for future research.MethodsWe searched for peer-reviewed literature published between 2017–2022 in MEDLINE, Cochrane Library, and Scopus using key terms related to dementia, primary care, and comorbidity. The literature was screened for relevance by title-abstract screening and subsequent full-text screening. The prioritized papers were categorized as either ‘Risk Assessment and Prevention’, ‘Screening, Detection, and Diagnosis’ or ‘Management’ and were further labelled as either ‘Tools and Technologies’, ‘Recommendations for Clinical Practice’ or ‘Programs and Initiatives’. ResultsWe identified 1,058 unique records in our search and respectively excluded 800 and 230 publications during title-abstract and full-text screening. Twenty-eight articles were included in our review, where ~ 50% describe the development and testing of tools and technologies that use pre-existing conditions to assess dementia risk. Only one publication provides official dementia screening guidelines for PCPs in people with pre-existing conditions. About 30% of the articles discuss managing the care of PwD, where most were anchored around models of multidisciplinary care and mitigating potentially inappropriate prescribing. ConclusionTo our knowledge, this is the first scoping review that examines the role for PCPs in the prevention, detection/diagnosis and management of dementia in the context of comorbidities. Given our findings, we recommend that future studies: 1) further validate tools for risk assessment, timely detection and diagnosis that incorporate other health conditions; 2) provide additional guidance into how comorbidities could impact dementia care (including prescribing medication) in primary care settings; 3) incorporate comorbidities into primary care quality indicators for dementia; and 4) explore how to best incorporate dementia and comorbidities into models/frameworks of holistic, person-centred care.

Short and long-term predictors of pain severity and interference in primary care patients with chronic musculoskeletal pain and depression

BackgroundChronic pain and depression are frequent comorbidities in primary care. Depression among other psychosocial factors play a role in the clinical course of chronic pain.ObjectiveTo study the short and long-term predictive factors of severity and interference of chronic pain in primary care patients with chronic musculoskeletal pain and major depression.MethodsLongitudinal study of a cohort of 317 patients. The outcomes are severity and functional interference of pain (Brief Pain Inventory) measured at 3 and 12 months. We performed multivariate linear regression models to estimate the effects the explanatory baseline variables on the outcomes.Results83% participants were women; average age was 60.3 years (SD = 10.2). In multivariate models, baseline pain severity predicted pain severity at 3 months (β = 0.53; 95% CI = 0.37–0.68) and at 12 months (β = 0.48; 95% CI = 0.29–0.67). Also, pain > 2 years of evolution predicted long term pain severity (β = 0.91; CI95%=0.11–1.71). Baseline pain interference predicted interference at 3 and 12 months (β = 0.27; 95%CI = 0.11–0.43 and β = 0.21; 95%CI = 0.03–0.40, respectively). Baseline pain severity predicted interference at 3 and 12 months (β = 0.26; 95%CI = 0.10–0.42 and β = 0.20; 95%CI = 0.02–0.39, respectively). Pain > 2 years predicted greater severity and greater interference at 12 months (β = 0.91; CI95%=0.11–1.71, and β = 1.23; CI95%=0.41–2.04). Depression severity predicted more interference at 12 months (β = 0.58; CI95%=0.04–1.11). Occupational status as active worker predicted less interference throughout the follow-up (β=-0.74; CI95%=-1.36 to -0.13 and β=-0.96; CI95%=-1.71 to -0.21, at 3 and 12 months). Currently working also predicts less pain severity at 12 months (β=-0.77; CI95%=1.52 − 0.02). With regard to the psychological variables, pain catastrophizing predicted pain severity and interference at three months (β = 0.03; 95% CI = 0.00-0.05 and β = 0.03; 95% CI = 0.00-0.05), but not at long term.ConclusionIn a sample of adults with chronic pain and depression, this primary care study has identified prognostic factors that independently predict the severity and functional interference of pain. If confirmed in new studies, these factors should be targeted for individualized interventions.Trial registrationClinicalTrials.gov (NCT02605278), registered 16/11/2015.

An Assessment of HIV Risk, Perceptions of Risk, and Potential Adherence to Preexposure Prophylaxis Among HIV-Negative People With Injection Drug Use Who Access Mobile Outreach Services.

The purpose of this study was to assess HIV risk, perceptions of risk, and potential adherence to preexposure prophylaxis (PrEP) for the prevention of HIV infection among people who inject drugs (PWID), who self-report HIV negative status and access mobile outreach intravenous drug use (IVDU) services. Participants (N = 93) were non-Hispanic White (59.1%) and Hispanic (36.6%), between the ages of 18 and 63 years, primarily male (58.1%), who reported a length of IVDU between 1 and >20 years and accessed mobile outreach IVDU services in a metropolitan area of the Southwestern United States; all self-reported HIV-negative status. Self-report questionnaires completed via iPad included HIV risk behavior, perceived risk of HIV, and beliefs about medicines. PWID perceived themselves at a low risk for HIV with minimal concerns about contracting HIV. High levels of comorbidities (schizophrenia, anxiety, depression, hepatitis, diabetes, and hypertension), substance use, and limited HIV protective behavior and social support existed; women reported significantly more risk behaviors and comorbidities. Positive attitudes toward and interest in use of medication for HIV prevention were present, however, with concurrent concerns regarding long-term medication use and the potential to forget medications. PrEP adherence for PWID presents challenges for clinicians. Addressing perceptions of PrEP, perceived and actual risk for contracting HIV, potential barriers to PrEP adherence, social support, and treatment of comorbidities in primary care and IVDU outreach services potentially enhances PrEP maintenance among PWID, notably women.

Management of diabetes patients with comorbidity in primary care: a mixed-method study in Odisha, India.

Diabetes patients with comorbidities need regular and comprehensive care for their disease management. Hence, it is essential to assess the primary care preparedness for managing diabetes patients and the perspectives of the diabetes patients on the care received at the primary care facilities. All 21 Urban Primary Health Centres (UPHCs) in Bhubaneswar city of Odisha, India, were assessed using the modified Primary Care Evaluation Tool and WHO Package of Essential Non-communicable disease interventions questionnaire. Additionally, 21 diabetes patients with comorbidities were interviewed in-depth to explore their perception of the care received at the primary care facilities. All the UPHCs had provisions to meet the basic requirements for the management of diabetes and common comorbidities like hypertension. There were few provisions for chronic kidney illness, cardiovascular disease, mental health, and cancer. Diabetes patients felt that frequent change in primary care physicians at the primary care facilities affected their continuity of care. Easy accessibility, availability of free medicines, and provisions of basic laboratory tests at the facilities were felt to be necessary by the diabetes patients. Our study highlights the existing gaps in India's healthcare system preparedness and the needs of diabetes patients with comorbidity. The government of India's Health and Wellness (HWC) scheme aims to deliver comprehensive healthcare to the population and provide holistic care at the primary care level for NCD patients. It is imperative that there is an early implementation of the various components of the HWC scheme to provide optimal care to diabetes patients.

Effectiveness of a Psychoeducational Group Intervention Carried Out by Nurses for Patients with Depression and Physical Comorbidity in Primary Care: Randomized Clinical Trial.

The association between physical illness and depression implies a poorer management of chronic disease and a lower response to antidepressant treatments. Our study evaluates the effectiveness of a psychoeducational group intervention led by Primary Care (PC) nurses, aimed at patients of this kind. It is a randomized, multicenter clinical trial with intervention (IG) and control groups (CG), blind response variables, and a one year follow-up. The study included 380 patients ≥50 years of age from 18 PC teams. The participants presented depression (BDI-II > 12) and a physical comorbidity: diabetes mellitus type 2, ischemic heart disease, chronic obstructive pulmonary disease, and/or asthma. The IG (n = 204) received the psychoeducational intervention (12 weekly sessions of 90 min), and the CG (n = 176) had standard care. The patients were evaluated at baseline, and at 4 and 12 months. The main outcome measures were clinical remission of depressive symptoms (BDI-II ≤ 13) and therapeutic response (reduction of depressive symptoms by 50%). Remission was not significant at four months. At 12 months it was 53.9% in the IG and 41.5% in the CG. (OR = 0.61, 95% CI, 0.49–0.76). At 4 months the response in the IG (OR = 0.59, 95% CI, 0.44–0.78) was significant, but not at 12 months. The psychoeducational group intervention led by PC nurses for individuals with depression and physical comorbidity has been shown to be effective for remission at long-term and for therapeutic response at short-term.

Interventions for improving outcomes in patients with multimorbidity in primary care and community settings.

Many people with chronic disease have more than one chronic condition, which is referred to as multimorbidity. The term comorbidity is also used but this is now taken to mean that there is a defined index condition with other linked conditions, for example diabetes and cardiovascular disease. It is also used when there are combinations of defined conditions that commonly co-exist, for example diabetes and depression. While this is not a new phenomenon, there is greater recognition of its impact and the importance of improving outcomes for individuals affected. Research in the area to date has focused mainly on descriptive epidemiology and impact assessment. There has been limited exploration of the effectiveness of interventions to improve outcomes for people with multimorbidity. To determine the effectiveness of health-service or patient-oriented interventions designed to improve outcomes in people with multimorbidity in primary care and community settings. Multimorbidity was defined as two or more chronic conditions in the same individual. We searched MEDLINE, EMBASE, CINAHL and seven other databases to 28 September 2015. We also searched grey literature and consulted experts in the field for completed or ongoing studies. Two review authors independently screened and selected studies for inclusion. We considered randomised controlled trials (RCTs), non-randomised clinical trials (NRCTs), controlled before-after studies (CBAs), and interrupted time series analyses (ITS) evaluating interventions to improve outcomes for people with multimorbidity in primary care and community settings. Multimorbidity was defined as two or more chronic conditions in the same individual. This includes studies where participants can have combinations of any condition or have combinations of pre-specified common conditions (comorbidity), for example, hypertension and cardiovascular disease. The comparison was usual care as delivered in that setting. Two review authors independently extracted data from the included studies, evaluated study quality, and judged the certainty of the evidence using the GRADE approach. We conducted a meta-analysis of the results where possible and carried out a narrative synthesis for the remainder of the results. We present the results in a 'Summary of findings' table and tabular format to show effect sizes across all outcome types. We identified 17 RCTs examining a range of complex interventions for people with multimorbidity. Nine studies focused on defined comorbid conditions with an emphasis on depression, diabetes and cardiovascular disease. The remaining studies focused on multimorbidity, generally in older people. In 11 studies, the predominant intervention element was a change to the organisation of care delivery, usually through case management or enhanced multidisciplinary team work. In six studies, the interventions were predominantly patient-oriented, for example, educational or self-management support-type interventions delivered directly to participants. Overall our confidence in the results regarding the effectiveness of interventions ranged from low to high certainty. There was little or no difference in clinical outcomes (based on moderate certainty evidence). Mental health outcomes improved (based on high certainty evidence) and there were modest reductions in mean depression scores for the comorbidity studies that targeted participants with depression (standardized mean difference (SMD) -0.41, 95% confidence interval (CI) -0.63 to -0.2). There was probably a small improvement in patient-reported outcomes (moderate certainty evidence). The intervention may make little or no difference to health service use (low certainty evidence), may slightly improve medication adherence (low certainty evidence), probably slightly improves patient-related health behaviours (moderate certainty evidence), and probably improves provider behaviour in terms of prescribing behaviour and quality of care (moderate certainty evidence). Cost data were limited. This review identifies the emerging evidence to support policy for the management of people with multimorbidity and common comorbidities in primary care and community settings. There are remaining uncertainties about the effectiveness of interventions for people with multimorbidity in general due to the relatively small number of RCTs conducted in this area to date, with mixed findings overall. It is possible that the findings may change with the inclusion of large ongoing well-organised trials in future updates. The results suggest an improvement in health outcomes if interventions can be targeted at risk factors such as depression in people with co-morbidity.

Frequency of Depression among Patients with Backache presenting to Mardan Medical Complex, Mardan

Background: Chronic pain accompanies emotional element in the form of psychiatric disorders. Chronic medical conditions such as backache may make a person at higher risk for depression. Depressed patients also have somatic symptoms as headache, fatigue, and backache. To understand the relationship, we conducted this study at neurosurgery Outpatient department of Mardan medical complex, Mardan.Objective: The aim of this study was to clarify the causal relationship of backache and depression. The study also aimed to explore the frequency of depression among patients with backache.Material and Methods: This cross-sectional study was conducted at outpatient department of Mardan Medical Complex. Patients presenting with chief complaints of backache were invited for participation in the study. initial medical and neurological screening was conducted by consultant neurosurgeon and afterwards HAM-D was administered for assessment of depression. Results: We included 114 male and female patients ranging in age from 22 to 58 years, who presented to neurosurgery OPD with chief complaints of backache. More than half 58% of the patients were female. Minimal depression was found among 22 (19.3%) of the patients, 19 (16.7%) patients had mild depression, 47 (41.2%) had moderate depression, and 26 (22.8%) had severe depression. Highest frequency of depression was observed among patients with infection/ tumor (84.5 %) and those with degenerative backache (79 %). The correlation of type of backache and severity of depression was significant (p= .049). Conclusion: Depression is common among patients with backache, therefore screening patients with complaints of backache for psychiatric co morbidity in primary care is important because psychopathology may have significant consequences for prognosis, outcome and health care utilization.

Personality disorder co-morbidity in primary care 'Improving Access to Psychological Therapy' (IAPT) services: a qualitative study exploring patient perspectives on treatment experience.

High numbers of people present with common mental health disorders and co-morbid personality disorder traits in primary care 'Improving Access to Psychological Therapies' (IAPT) services in England and they receive sub-optimal treatments. No previous studies have explored the treatment experiences or needs of this patient population in England. This qualitative study explored the treatment experiences of patients (n = 22) with common mental health difficulties and co-morbid personality disorder as indicated by a score of 3 or more on the 'Standardised Assessment of Personality - Abbreviated Scale' (SAPAS) in receipt of primary care-based IAPT treatment. A qualitative health research approach was used. Qualitative individual face-to-face semi-structured interviews were conducted. All interviews were audio recorded, data were transcribed verbatim and analysed using a framework analysis approach. Findings revealed a need to adapt away from prescriptive cognitive behavioural therapy (CBT) treatment models towards more flexible, personalised and individualised treatment with this patient group. Time to emotionally offload, build a therapeutic relationship and link past experiences to presenting problems were highlighted as important. For the first time, the needs and treatment experiences of this patient group have been explored. This paper provides a unique patient experience insight that should be considered when exploring new approaches to working with and developing effective interventions via a stepped care approach.

The use of functional performance tests and simple anthropomorphic measures to screen for comorbidity in primary care.

Many older adults are unaware that they have comorbid diseases. Increased adiposity and reduced muscle mass are identified as key contributors to many chronic diseases in older adults. Understanding the role they play in the development of comorbidities in older populations is of prime importance. To identify the optimal body shape associated with three common functional performance tests and to determine which anthropometric and functional performance test best explains comorbidity in a sample of older adults in Hong Kong. A total of 432 older adults participated in this cross-sectional study. Researchers assessed their body height, body mass index, waist circumference, waist-to-hip ratio, handgrip strength (kg), functional reach (cm) and results in the timed-up-and-go (TUG) test (seconds). The Charlson Comorbidity Index was used to assess comorbidity. Allometric modelling indicated that the optimal body shape associated with all functional performance tests would have required the participants to be taller and leaner. The only variable that predicted comorbidity was the TUG test. The inclusion of body size/shape variables did not improve the prediction model. Performance in the TUG test alone was found to be capable of identifying participants at risk of developing comorbidities. The TUG test has potential as a screening tool for the early detection of chronic diseases in older adults. Many older people are unaware of their own co-existing illnesses when they consult physicians for a medical condition. TUG can be a quick and useful screening measure to alert nurses in primary care to the need to proceed with more detailed assessments. It is an especially useful screening measure in settings with high patient volumes and fiscal constraints. TUG is low cost and easy to learn and is therefore also relevant for nurses and health workers in low-resource, low-income countries.

Treatment of COPD and COPD-heart failure comorbidity in primary care in different stages of the disease.

Chronic obstructive pulmonary disease (COPD) is a chronic respiratory disease that may have a negative impact on both patients' quality of life and survival. Patients with COPD frequently suffer from heart failure (HF), likely owing to several shared risk factors. To evaluate the differences in treatment of COPD with and without HF comorbidity according to COPD severity in the general practitioner setting. We conducted an observational, retrospective study using data obtained from the Italian Health Search Database, which collects information generated by the routine activity of general practitioners. The study sample included 225 patients with COPD, alone or combined with HF. It has been found that the prevalence of some comorbidities such as diabetes and HF significantly increases with the severity of COPD. Regarding pharmacological treatment, a reduction in the prescription of individually administered long-acting β 2-agonists (LABAs) and long-acting anticholinergics (LAMAs) has been observed with increasing severity of the disease. Moreover, an increase in the prescription of both the combination of the two bronchodilators (LABA + LAMA) and their association with inhaled corticosteroids has been observed with increasing severity of COPD. The prescription of β-blockers in patients with COPD suffering from HF comorbidity decreases from 100% in stage I to less than 50% in the other stages of COPD. This study shows that general practitioners do not follow the guidelines recommendations for the management of patients with COPD in the different stages of the disease, with and without HF comorbidity, as well as in the management of HF. Further efforts must be made to ensure adequate treatment for these patients.

Antibiotic Prescribing Before and After the Diagnosis of Comorbidity: A Cohort Study Using Primary Care Electronic Health Records.

Comorbidities such as diabetes and chronic obstructive pulmonary disease (COPD) increase patients' susceptibility to infections, but it is unclear how the onset of comorbidity impacts antibiotic use. We estimated rates of antibiotic use before and after diagnosis of comorbidity in primary care to identify opportunities for antibiotic stewardship. We analyzed UK primary care records from the Clinical Practice Research Datalink. Adults registered between 2008-2015 without prior comorbidity diagnoses were eligible for inclusion. Monthly adjusted rates of antibiotic prescribing were estimated for patients with new-onset stroke, coronary heart disease, heart failure, peripheral arterial disease, asthma, chronic kidney disease, diabetes, or COPD in the 12 months before and after diagnosis and for controls without comorbidity. 106 540/1 071 943 (9.9%) eligible patients were diagnosed with comorbidity. Antibiotic prescribing rates increased 1.9- to 2.3-fold in the 4-9 months preceding diagnosis of asthma, heart failure, and COPD before declining to stable levels within 2 months after diagnosis. A less marked trend was seen for diabetes (rate ratio, 1.55; 95% confidence interval, 1.48-1.61). Prescribing rates for patients with vascular conditions increased immediately before diagnosis and remained 30%-39% higher than baseline afterwards. Rates of prescribing to controls increased by 17%-28% in the months just before and after consultation. Antibiotic prescribing increased rapidly before diagnosis of conditions that present with respiratory symptoms (COPD, heart failure, asthma) and declined afterward. Onset of respiratory symptoms may be misdiagnosed as infection. Earlier diagnosis of these comorbidities could reduce avoidable antibiotic prescribing.

Comprehensive Care Protocol in New Diagnosis of Type 2 Diabetes Mellitus and Associated Comorbidities in Primary Care

Comprehensive Care Protocol in New Diagnosis of Type 2 Diabetes Mellitus and Associated Comorbidities in Primary Care

Gender-Stratified Prevalence of Psychiatric and Pain Diagnoses in a Primary Care Patient Sample with Fibromyalgia.

Comorbid psychiatric and pain-related conditions are common in patients with fibromyalgia. Most studies in this area have used data from patients in specialty care and may not represent the characteristics of fibromyalgia in primary care patients. We sought to fill gaps in the literature by determining if the association between psychiatric diagnoses, conditions associated with chronic pain, and fibromyalgia differed by gender in a primary care patient population. Retrospective cohort. Medical record data obtained from 38,976 patients, ≥18 years of age with a primary care encounter between July 1, 2008, to June 30, 2016. International Classification of Diseases-9 codes were used to define fibromyalgia, psychiatric diagnoses, and conditions associated with chronic pain. Unadjusted associations between patient demographics, comorbid conditions, and fibromyalgia were computed using binary logistic regression for the entire cohort and separately by gender. Overall, 4.6% of the sample had a fibromyalgia diagnosis, of whom 76.1% were women. Comorbid conditions were more prevalent among patients with vs without fibromyalgia. Depression and arthritis were more strongly related to fibromyalgia among women (odds ratio [OR] = 2.80, 95% confidence interval [CI] = 2.50-3.13; and OR = 5.19, 95% CI = 4.62-5.84) compared with men (OR = 2.16, 95% CI = 1.71-2.71; and (OR = 3.91, 95% CI = 3.22-4.75). The relationship of fibromyalgia and other diagnoses did not significantly differ by gender. Except for depression and arthritis, the burden of comorbid conditions in patients with fibromyalgia is similar in women and men treated in primary care. Fibromyalgia comorbidities in primary care are similar to those found in specialty care.

Comorbidity in Family Medicine - Causal or Casual? What is the Effect of Illness Diversity? A Longitudinal Observational Study in Primary Care

Background: This is a study of casual versus causal comorbidity in family medicine in three practice populations. Methods: Participating family doctors (FDs) in the Netherlands, Malta and Serbia recorded details of all patient contacts in an episode of care structure using electronic medical records based on the International Classification of Primary Care, collecting data on all elements of the doctor-patient encounter, including the diagnostic labels (episode of care labels, EoCs). The databases included 15,318 patients and 158,370 patient years over 11 years in the Netherlands (1995-2005), 9,896 patients and 43,577 patient years of observation over 5 years in Malta (2001-2005), 72,673 patient years over 1 year in Serbia (2003). Comorbidity was measured using the odds ratio of both conditions being incident or rest-prevalent in the same patient in one-year dataframes, as against not. Findings: Comorbidity in family practice in the three population databases expressed as odds ratios between the 41 joint most prevalent (joint top 20) episode titles in the three populations. Specific associations were explored in different age groups to observe the changes in odds ratios with increasing age as a surrogate for a temporal or biological gradient. Interpretation: After applying accepted criteria for testing the causality of associations, it is reasonable to conclude that most of the observed primary care comorbidity is casual. It would be incorrect to assume causal relationships between co-occurring diseases in family medicine, even if such a relationship might be plausible or consistent with current conceptualisations of the causation of disease. Most observed comorbidity in primary care is the result of increasing illness diversity. Funding Statement: This study was self-funded by the authors. Declaration of Interests: All authors have completed the ICMJE uniform disclosure form and declare: “no support from any organisation for the submitted work, no financial relationships with any organisations that might have an interest in the submitted work in the previous three years and no other relationships or activities that could appear to have influenced the submitted work.” Ethics Approval Statement: The study did not involve the collection of new data. Ethical approval was applied for locally, when appropriate, for the original data collection and for individual studies based on these data in the Netherlands, Malta and Serbia.